Provider Demographics
NPI:1225203250
Name:WITTER, AVERY ERASMUS
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:ERASMUS
Last Name:WITTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Mailing Address - City:FT. GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:706-787-5373
Mailing Address - Fax:
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Practice Address - City:FT. GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN